The role of the immune system in osteoarthritis: mechanisms, challenges and future directions

Osteoarthritis (OA) is a chronic joint disease that has long been considered a simple wear-and-tear condition. Over the past decade, research has revealed that various inflammatory features of OA, such as low-grade peripheral inflammation and synovitis, contribute substantially to the pathophysiology of the disease. Technological advances in the past 5 years have revealed a large diversity of innate and adaptive immune cells in the joints, particularly in the synovium and infrapatellar fat pad. Notably, the presence of synovial lymphoid structures, circulating autoantibodies and alterations in memory T cell and B cell populations have been documented in OA. These data indicate a potential contribution of self-reactivity to the disease pathogenesis, blurring the often narrow and inaccurate line between chronic inflammatory and autoimmune diseases. The diverse immune changes associated with OA pathogenesis can vary across disease phenotypes, and a better characterization of their underlying molecular endotypes will be key to stratifying patients, designing novel therapeutic approaches and ultimately ameliorating treatment allocation. Furthermore, examining both articular and systemic alterations, including changes in the gut–joint axis and microbial dysbiosis, could open up novel avenues for OA management. This Review provides an update on the role of innate and adaptive immune cells in the pathogenesis of osteoarthritis. The authors discuss emerging therapeutics that target the immune system in osteoarthritis and the challenges that limit the movement towards personalized medicine.